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FA L L 2 0 1 6
1 PrehospitalAirwayManagement
4 TopicalHemostaticsinthePrehospitalSetting
6
“SurgicalRescue”andtheSystem-WideManagementofSurgicalComplications
8 ContinuingEducation
For emergency medicine and trauma professionals
Accreditation Statement: The University of Pittsburgh School of
Medicine is accredited by the Accreditation Council for Continuing
Medical Education (ACCME) to provide continuing medical education
for physicians. The University of Pittsburgh School of Medicine
designates this enduring material for a maximum of .5 AMA PRA
Category 1 Credits™. Each physician should only claim credit
commensurate with the extent of their participation in the
activity. Other health care professionals are awarded .05
continuing education units (CEU), which are equivalent to .5
contact hours.
Disclosures: The authors have no conflicts of interest to
disclose.
Instructions: To take the CME evaluation and receive credit,
please visit https://cme.hs.pitt.edu/ISER (case-sensitive) and
click on Trauma and Emergency. If this is your first visit, you
will need to create a free account.
roun
dsTRAUMA
In This Issue
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PrehospitalAirwayManagementby Francis Guyette, MD, MS, MPH,
FACEP
A 36-year-old woman, weighing 60 kg, was driving her SUV without
wearing her seatbelt and was thrown from her vehicle. You and your
EMT partner are the first unit on scene. After determining that the
scene is safe, you perform a primary survey by opening the
patient’s airway and observe that she is not breathing adequately.
The patient’s rating on the Glasgow Coma Scale (GCS) is 3; her
blood pressure is 104/50 mm Hg; her pulse measures 128 beats per
minute; she has a respiratory rate of 6 breaths per minute; and her
oxygen saturations are 90% on room air.
You assess the patient’s airway using the LEMON method (see
Figure 1). Your EMT partner begins to assist the patient with a bag
valve mask (BVM), delivering 100% oxygen. You
Figure 1: The LEMON Airway Assessment Method
Follow the steps outlined in the LEMON method to evaluate
patients with a potentially difficult airway.
• Look externally. If a patient may require intubation, look for
characteristics that generally predict a potentially difficult
airway.
• Evaluate, using the 3-3-2 rule. The patient should be able to
fit three fingers into the mouth, three fingers from the angle of
the jaw to the chin, and two fingers between the Adam’s apple and
the bottom of the jaw.
• Mallampati score. Perform a Mallampati evaluation by opening
the patient’s mouth. The more of the uvula that can be seen, the
easier the airway.
• Obstruction. Look for anything that might obstruct the
oropharynx, including soft tissue swelling or foreign bodies in the
airway.
• Neck mobility. Be aware that patients with limited neck
mobility may not be able to be moved into the optimal position for
intubation.
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prepare your equipment for intubation, ensuring that you have
adequate suction and that the patient is on the monitor. When your
partner is ready to remove the BVM, you ask her to place the
patient on a nasal cannula at 6 liters per minute (LPM). Both a 7.5
mm and a 7.0 mm endotracheal tube (ETT) are placed next to the
patient. You check the balloon and insert a stylet into the ETT,
ensuring that the stylet does not go past the “Murphy eye” of the
tube. A waveform capnography is connected, as is a commercial tube
holder. From your airway bag, you take out a size 4 King LTS-D
device, which is an airway management tool that can be used as a
rescue device if needed. Your partner has been assisting the
patient, who now has a blood oxygen saturation level of 99%. You
suction blood from the patient’s mouth and place the ETT through
the vocal cords. You inflate the balloon, listen to the patient’s
breath sounds, and connect the End-Tidal CO
2 (EtCO
2). The tube is secured while your EMT partner
reassesses the patient’s vitals. You perform a secondary survey
and prepare your patient for transport to the closest trauma
center.
Prehospital airway management should always be considered
difficult airway management. Prehospital providers must contend
with limited equipment and resources, as well as a host of
unpredictable factors, including suboptimal lighting, position, and
weather. Successful prehospital airway management requires good
judgment, training, and a plan, known as an airway algorithm (see
Figure 2).
A prehospital airway management algorithm should begin with the
provider performing an initial assessment, including the
compressions, airway, breathing (CAB) sequence and initiation of
basic life support (BLS) airway management. If a trauma patient is
not perfusing, then hemorrhage and other life threats may need to
be addressed first. For patients in extremis, ideally one provider
will administer BLS airway management while the other performs
life-saving interventions.
If the providers are not able to ventilate or oxygenate, they
should immediately call for help. Calling for help in the field
might mean asking for an additional unit or a supervisor, or
driving to the closest hospital. If they are able to ventilate and
oxygenate using BLS skills, then they should reassess the patient
to determine if invasive airway management will be necessary. If
endotracheal intubation (ETI) fails, adequately ventilated patients
might warrant a second attempt with actions designed to improve
intubating conditions (better positioning, different blade, or
different operator).
Those who cannot be ventilated need additional resources, such
as a supraglottic airway (SGA) device or surgical airway. Airway
attempts should be limited to two per operator, as the probability
of success drops dramatically after the second attempt.
Basic airway interventions provide supplemental oxygen and/or
ventilation without an ETT or supraglottic device. Basic airway
interventions should be mastered by providers of all skill levels.
Patients who are breathing spontaneously should be placed on the
lowest level of oxygen to maintain saturations > 94%. Patients
in need of an advanced airway should be placed on a high-flow mask
in order to allow the lungs to denitrogenate and provide a
reservoir of oxygen for intubation. Patients who are not
spontaneously breathing should be immediately supplemented by BVM
ventilation. Because BVM ventilation can be difficult, this skill
should be practiced using both one-handed and two-handed techniques
with and without adjuncts, such as nasal trumpets and oropharyngeal
airways. A two-handed technique that utilizes a jaw thrust into the
mask is especially useful in a trauma patient. Continuous positive
airway pressure (CPAP) may be used to reduce the work of breathing
and to improve oxygenation in a spontaneously breathing patient.
While CPAP use is limited in trauma patients, it may help to
preoxygenate select patients prior to intubation.
PrehospitalAirwayManagement(Continued from Page 1)
Figure 2: Emergency Airway Management Algorithm
Need for Airway Management Identified Initial Intubation
Attempt
SuccessConfirmation
Fail
Fail
Fail Fail
Adequate Oxygenation? Call for Help
Attempt 2with Optimization
Attempt 3with Optimization
Non-SurgicalBlind Device
Surgical Airway
SuccessConfirmation
SuccessConfirmation
SuccessConfirmation
Definitive Planning
Notifications / Assemble Team
Pre-OxygenationConsider BVM
Consider Apneic OxygenationConsider Oral / Naso Pharyngeal
Airway
Examine Patient
Check EquipmentVerbalize
Challenge / Response
Assess PotentialDifficulty
HistoryPhysical Exam
Current CircumstancesConsider Video
Decide Back Up Plan
BVM & O2 OnSuction FunctioningFunctional IVPulse
OxEKGSyringeTube(s)Cuff CheckStyletHandleBlade(s)Light
SourceConfirmation DeviceBack Up Equipment
Announce Back UpPlan to Team
Proceed
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ETI is the most widely recognized method of invasive airway
management performed by prehospital providers. ETI places a cuffed
ETT below the vocal cords, providing for a stable airway with
reduced risk of aspiration. However, ETI may result in failed
intubation, unrecognized esophageal intubation, hypoxia,
hypotension, bradycardia, aspiration, or airway trauma. The risks
of ETI are compounded when performed by a provider who lacks
experience; the average paramedic in Pennsylvania intubates only
1.5 times per year. This risk can be mitigated through improved
training with the proper equipment, including practice in the
operating room, simulation, and the use of adjuncts such as the gum
elastic bougie or video laryngoscopy.
Prior to the first intubation attempt, all equipment necessary
for ETI should be prepared using a checklist (see Figure 3), and
the patient should be preoxygenated as described above. The patient
should then be placed on a nasal cannula providing 6 to 15 LPM of
flow for passive oxygenation during the intubation attempt. If
drug-assisted intubation is available, rapid or delayed sequence
induction should be provided with a sedative hypnotic agent.
Current practice would suggest that etomidate or ketamine are the
preferred agents for trauma, as they are least likely to negatively
impact blood pressure. Ideally, sedation would be followed by use
of a paralytic agent to eliminate airway reflexes and maximize the
opportunity for successful ETI. Trauma patients should be held in
cervical motion restriction from below while the collar is removed,
allowing for jaw thrust and better visualization during ETI. Video
laryngoscopy may have added benefits, including improved
visualization of the vocal cords and decreased cervical motion, but
this method requires additional cost and training. ETI attempts
should be limited to two (blade past the teeth), at which point the
provider should move to the next step in
the difficult airway algorithm. ETI must be confirmed by EtCO2
and
monitored for vital sign abnormalities, including hypoxia,
hypotension, and bradycardia.
An SGA device is typically used as a rescue tool when ETI fails,
but may also be used as a primary airway for presumed difficult
intubation if the patient has no protective reflexes. Following SGA
placement, the airway must be confirmed and secured, similar to
ETI. If possible, the stomach should be decompressed and the trauma
team should be advised that an SGA device was used. As part of the
failed airway algorithm, the provider must consider the option of
surgical airway management. In rare circumstances, when the patient
cannot be intubated or ventilated, surgical airway management may
be the only viable option.
A comprehensive strategy for trauma airway management is
necessary for all prehospital providers. For BLS providers, this
should include skills with oxygen delivery, BVMs, and airway
adjuncts. For advanced life support (ALS) providers, training in
ETI, SGAs, and surgical airways provides the tools necessary to
treat patients with difficult airways.
Francis Guyette, MD, MS, MPH, FACEP, is associate professor of
Emergency Medicine at University of Pittsburgh School of Medicine
and medical director of STAT MedEvac. He earned his medical degree
from Tulane University and completed his residency, fellowship, and
public health training at University of Pittsburgh School of
Medicine.
References1 Wang HE, Yealy DM. How many attempts are required to
accomplish
out-of-hospital endotracheal intubation? Acad Emerg Med. Apr
2006; 13(4):372-377.
2 Reed MJ, et al. Can an airway assessment score predict
difficulty at intubation in the emergency department? Emerg Med J
2005 Feb; 22:99-102.
3 Guyette FX and Wang HE (2015). EMS Airway Management. In Cone
D, Brice J, Delbridge T, Myers B, Emergency Medical Services
Clinical Practice and Systems Oversight. John Wiley and Sons,
Hoboken.
4 Wang HE, Mann NC, Mears G, Jacobson K, Yealy DM.
Out-of-hospital airway management in the United States.
Resuscitation. Apr 2011; 82(4):378-385.
5 Warner KJ, Sharar SR, Copass MK, Bulger EM. Prehospital
management of the difficult airway: a prospective cohort study. The
Journal of emergency medicine. Apr 2009; 36(3):257-265.
6 Wang HE, Kupas DF, Greenwood MJ, et al. An algorithmic
approach to prehospital airway management. Prehosp Emerg Care.
Apr-Jun 2005; 9(2):145-155.
Figure 3: Intubation Preparation Check List
BVM and O2 on
Nasal cannula on for apneic oxygenation
Functional IV (for medication-assisted intubation)
Monitor (Electrocardiogram, Pulse Oximeter, EtCO2)
10 ml syringe
Tube(s)
Cuff check
Stylet
Blade(s)
Handle (video system)
Light
Confirmation devices
Commercial tube holder
Back-up plan
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Uncontrolled hemorrhage is a leading cause of potentially
preventable death from traumatic injuries.1,2 The two most
important interventions utilized to control hemorrhage in the
prehospital setting are tourniquets and topical hemostatic agents.
Topical hemostasis is a process that acts locally on a bleeding
vessel to control hemorrhage. Below is a review of currently
available topical hemostatic agents, explanations of how they work,
and an overview of their relative effectiveness. Pennsylvania
Statewide Basic Life Support (BLS) Protocols for Bleeding Control
require that a commercial tourniquet be carried on every
BLS/Advanced Life Support (ALS) ambulance and Quick Response
Service (QRS). Hemostatic agents are optional, and approved agents
may be used by appropriately trained providers with the following
requirements:
1) The agency and agency medical director must ensure that all
providers who will potentially use the hemostatic agent are trained
in its use.
2) Hemostatic agents that are impregnated into gauze that can be
packed into a wound are preferred. Otherwise, the hemostatic agent
must be contained within a packet. Free powders are not
approved.3
During the military conflicts in Iraq and Afghanistan, the U.S.
Army Institute of Surgical Research developed a standard animal
model for testing hemostatic agents to be able to compare how
effectively they stop bleeding. Despite numerous studies using both
animal models and case series of human uses, no single hemostatic
dressing has been found to be consistently the most effective. When
considering the purchase of a hemostatic dressing, multiple factors
will play into the decision4 (see Figure 1). The key is to choose
the agent that best meets your specific needs, as none possess all
ideal properties. Some first-generation topical agents generated
significant heat with application, causing pain and tissue damage.
Second- and third-generation agents generate little or no heat and
are useful in a variety of settings. Common indications for the use
of a topical hemostatic agent include penetrating wounds that are
not amenable to tour niquet placement, particularly junctional
wounds in the neck, groin, or axilla. Scalp wounds can lead to
significant blood loss and may not be easily wrapped in the field.
Hemostatic agents are also useful in patients on anticoagulants
with bleeding wounds.
Mechanisms and Active Agents
The process of coagulation is a complex mechanism that involves
vasoconstriction, formation of a platelet plug, and clotting of
blood. Topical hemostatics work through one of three
mechanisms.
Factor concentrators absorb water from the blood and concentrate
the clotting factors in the blood at the site of hemorrhage.
QuikClot® Granular and QuikClot Advanced Clotting Sponge, both made
by
Z-Medica, are examples of factor concentrators. Factor
concentrators frequently contain zeolite, which is a naturally
occurring crystalline aluminosilicate mineral. It is a porous
material with cage-like cavities that attract water as well as
sodium and calcium ions. They trap large amounts of water in the
blood, which causes concentration of the clotting factors. The
original QuikClot Granular preparation is a zeolite powder.
However, because it generated heat upon application, it was removed
from Tactical Combat Casualty Care (TCCC) recommendations in 2008
when improved second-generation agents became available.5 The
QuikClot Advanced Clotting Sponge contains zeolite beads enclosed
in a mesh bag, which generate less heat than the earlier granular
version.
Procoagulants activate the blood coagulation cascade. QuikClot
Combat Gauze, also made by Z-Medica, is a procoagulant. The most
common procoagulant agent is kaolin, which is a clay-based
material. It is a naturally occurring aluminum silicate mineral
that activates the coagulation cascade, accelerating clot formation
in the wound. This is the active agent in Combat Gauze, which is
the first-line agent in the Committee for TCCC guidelines for the
U.S. military. Combat Gauze comes as a Z-fold to facilitate wound
packing. Proper application of Combat Gauze requires packing into
the wound and direct manual pressure to be held for three minutes,
or until active bleeding stops.
Mucoadhesives form a strong adherent seal over bleeding vessels
independent of the coagulation cascade.6 Mucoadhesive agents are
generally chitosan-based. Chitosan includes a series of polymers
that are derived from the shells of shrimp and other shellfish.
Chitosan does not have any actual clotting properties; instead, it
has a positive charge that attracts negatively charged blood cells
and platelets to form a gel that physically seals bleeding tissues.
There is no heat generated
TopicalHemostaticsinthePrehospitalSettingby Raquel M. Forsythe,
MD, FACS
Approved by appropriate regulatory agency
Quickly stops severe bleeding from arterial or venous
source
Lightweight and easy to carry
No systemic or local toxicity or reaction
No pain or injury with application
Long shelf life
Easy to apply to a variety of wound types
Can be used in austere environments
Cost-effective
Figure 1: Properties of the Ideal Hemostatic Agent
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during this reaction. Celox, made by Medtrade Products Ltd, and
ChitoGauze®, made by Tricol Biomedical Inc., are both
chitosan-based hemostatic agents.
Safe Use
Hemostatic agents are most likely to be indicated for wounds
involving the scalp, face, neck, axilla, groin, or buttocks.
Hemostatic agents are not appropriate for minor bleeding, bleeding
that can be controlled by direct pressure, bleeding that can be
controlled by application of a tourniquet, or bleeding from open
abdominal or chest wounds. The spring 2016 edition of Trauma Rounds
detailed the U.S. Department of Homeland Security’s “Stop the
Bleed” campaign, which is intended to empower everyone in the
community to save a life by learning hemorrhage control techniques.
Training, sponsored by UPMC, will be offered throughout western
Pennsylvania. As the Stop the Bleed initiative rolls out and
hemorrhage-control equipment becomes more commonly available in the
community, injured patients may have topical hemostatics applied by
law enforcement officers or the lay public prior to the arrival of
emergency medical professionals. If bleeding is controlled, any
applied hemostatics should be left in place until the patient’s
arrival in the emergency department. If ongoing bleeding is noted,
removal and reapplication is warranted.
What’s Next for Hemostatic Agents
Until all potentially preventable deaths from exsanguination are
eliminated, research on improving methods to control hemorrhage in
the field will continue. In December 2015, the U.S. Food and Drug
Administration approved the use of the XSTAT 30™ wound dressing,
which is an expandable, multi-sponge dressing for junctional wounds
for both military and civilian trauma settings.7 The first field
use occurred in a military setting in May 2016 and was successful.8
After further testing, this and other new types of topical
hemostatic agents may be available in the near future.
Raquel M. Forsythe, MD, FACS, is the associate medical director
of the Trauma Service at UPMC Presbyterian and associate program
director of the General Surgery Residency at University of
Pittsburgh School of Medicine. She teaches extensively in the
hospital and prehospital setting.
References1 Eastridge BJ, Mabry RL, Seguin P, et al. Death on
the Battlefield (2001-
2011): Implications for the future of combat casualty care. J
Trauma Acute Care Surg 2012; 73:S431-S437
2 Teixeira PG, Inaba K, Hadjizacharia P, et al. Preventable or
potentially preventable mortality at a mature trauma center. J
Trauma 2007; 63:1338-1346
3 Pennsylvania Department of Health, Bureau of Emergency Medical
Services. Pennsylvania Statewide Basic Life Support Protocols.
Accessed at
http://www.health.pa.gov/My%20Health/Emergency%20Medical%20Services/EMS%20Statewide%20Protocol/Pages/default.aspx#.V3XaqLgrK01
on June 28, 2016.
4 Grissom TE, Fang R. Topical hemostatic agents and dressings in
the prehospital setting. Curr Opin Anesthesiol 2015; 28:210-216
5 Bennett BL, Littlejohn L. Review of new topical hemostatic
dressings for combat casualty care. Mil Med 2014: 179:497-514
6 Pourshahrestani S, Zeimaran E, Djoordjevic I, et al. Inorganic
hemostats: The state of the art and recent advances. Materials
Science and Engineering C 2016:58:1255-1268
7 FDA News Release. Accessed at
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm475810.htm
on 6/30/2016.
8 RevMedX Press Release. Accessed at
http://www.ireachcontent.com/news-releases/revmedx-announces-first-field-use-of--xstat-
580244211.html on 6/30/2016.
Meet the UPMC Presbyterian Trauma/Acute Care Surgery Experts
Front row (left to right): Rani Schuchert, MD; Brian
Zuckerbraun, MD; Andrew Peitzman, MD; Louis Alarcon, MD; Matthew
Rosengart, MD, MPH; and Deepika Mohan, MD, MPH
Back row (left to right): Timothy Billiar, MD; Matthew Neal, MD;
Juan Carlos Puyana, MD; Raquel Forsythe, MD; Greg Watson, MD;
Graciela Bauza, MD; and Jason Sperry, MD
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The practices of trauma and emergency general surgery have
evolved rapidly over the past 20 years, aiming to meet the demands
of an aging population with increasingly complex medical and
surgical issues. In 2005, as part of this evolution, the American
Association for the Surgery of Trauma proposed the creation of a
new surgical specialty called “acute care surgery,”1 combining
training in trauma, emergency general surgery, and surgical
critical care. Including the fellowship at UPMC Presbyterian, there
are now 19 accredited acute care surgery fellowships providing the
newest generation of general surgeons with additional skills
focused on emergent management of “time-sensitive surgical
disease,”2 often at times of the day or in clinical settings in
which a specialist is not immediately available.3 Several studies
of the implementation of an acute care surgery-type model of
surgical care have shown improved efficiency, reduced delay to
operation, and shorter length of hospital stay for patients with
acute surgical conditions such as appendicitis4-7 and
cholecystitis,4, 8-11 while protecting the practice pattern and
operative volume of general surgeons at the same institution.12
Practitioners of acute care surgery also possess unique skills
in the management of patients with procedural complications.
According to Centers for Disease Control and Prevention figures, of
more than 36 million inpatient hospital discharges across the
United States in 2006, more than 900,000 were related to a
complication of medical or surgical care. This is a more common
discharge diagnosis than bowel obstruction, appendicitis, and
cholelithiasis combined.13 In fact, 40% of in-hospital
complications are related to an operative procedure, with
complications 2- to 4.5-fold more common in surgical patients as
compared to medical patients.14 Several recent, large studies
demonstrate that the incidence of complications across surgical
specialties at high-performing hospitals (those with risk-adjusted
low mortality rates) versus low-performing hospitals (those with
risk-adjusted high mortality rates) is not significantly different.
Instead, marked differences in mortality stem primarily from the
capacity to expeditiously and appropriately “rescue” patients from
the complication.15-20 The skills of the acute care surgeon are
uniquely tailored to the time-sensitive condition of such patients
and are particularly critical in maintaining good patient outcomes
in regional hospital systems as well as in individual hospitals
with active interventional and surgical specialty services.
As a nationally recognized leader in acute care surgery
research, the Division of Trauma and Acute Care Surgery at UPMC
Presbyterian has been at the forefront of investigating the
epidemiology, logistics, and best practices for management of
patients with a complication of an interventional or surgical
procedure, referred to as “surgical
rescue.”21 Surgical rescue is a provision of immediate care
(usually operative) to save the life of a patient who has a medical
or surgical care complication. These vulnerable patients require
immediate access to the operating room, intensive care unit (ICU),
general surgeons, blood bank, and surgical subspecialties available
at our institution. Analyzing UPMC Presbyterian’s electronic
medical records for the years 2013-2014, we used ICD-9 codes to
screen for patients who were evaluated by an acute care surgeon for
management of a surgical complication.22 We learned that 20% of the
patients on our Acute Care Surgery service were admitted
specifically to be rescued from a complication of previous care. Of
these complications, 88% were related to a previous operative
procedure, while 12% were the result of an interventional or
endoscopic procedure. Patients with a complication were, on
average, older; had a significantly higher incidence of anemia,
renal dysfunction, and shock during the course of their treatment;
and had longer ICU and hospital stays compared to patients seen for
other conditions. 82% of patients required an operation, and 53%
required ICU-level care in the management of their
complication.
Next, we investigated the circumstances of the original
complication in our “surgical rescue” population. The patients who
required surgical rescue originated primarily from other hospitals
in the region and from different services than patients from within
UPMC Presbyterian. Compared to UPMC Presbyterian patients, these
“regional” referrals were the most likely to require primary
operative therapy, as opposed to interventional procedures or
critical care. Importantly, the in-hospital (7%) and 30-day (10%)
mortality of patients transferred for surgical rescue were
statistically similar to patients whose complication occurred at
UPMC Presbyterian.
These findings coincide with evidence from nationwide
administrative databases suggesting that the incidence of surgical
complications is associated with individual patient
characteristics, while the morbidity and mortality resulting from
any given complication is primarily related to hospital
practices.23 A recent study of inpatient surgery, involving more
than 200,000 Medicare patients undergoing six major elective
operations, ranked hospitals into “high-performing” and
“low-performing” groups based on risk-adjusted mortality rates.
Surprisingly, complications occurred just as often in
high-performing as in low-performing hospitals; the better survival
rates in high-performing hospitals were the result of successful
management of complications, with low-performing hospitals “failing
to rescue” the patient with a complication.14 A systematic review
further
“SurgicalRescue”andtheSystem-WideManagementofSurgicalComplicationsby
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highlighted the fact that delay in the escalation of care
occurred in 20-50% of patients with a complication and was a
significant driver of associated mortality.24 As awareness of the
importance of rescue to hospital performance has grown over the
past decade, “failure to rescue” (defined as the mortality rate in
patients with a complication) is now being tracked as a quality
metric that is publicly reported at the hospital level.25, 26
This ongoing research highlights the importance of UPMC’s
regional transfer network to the optimal care of surgical patients,
as it provides hospitals in the region access to immediate
operating room availability; medical and surgical specialists;
advanced interventional and endoscopic services; and critical care
capacity, all of which are key in the surgical rescue of patients
with a complication.14 Our ongoing research aims to further
characterize best practices in surgical rescue, specifically
focusing on improvements in early patient identification,
information-sharing, and improved transfer protocols.
Matthew Kutcher, MD, is a trauma/acute care surgeon at the
University of Mississippi. He completed his trauma/acute care
surgery fellowship at UPMC and previously completed his residency
at the University of California San Francisco. Dr. Kutcher earned
his medical degree from Tufts University.
References1 Committee to Develop the Reorganized Specialty of
Trauma SCC, and
Emergency Surgery. Acute care surgery: trauma, critical care,
and emergency surgery. J Trauma 2005; 58(3):614-6.
2 Santry HP, Pringle PL, Collins CE, et al. A qualitative
analysis of acute care surgery in the United States: it’s more than
just “a competent surgeon with a sharp knife and a willing
attitude.” Surgery 2014; 155(5):809-25.
3 Davis KA, Dente CJ, Burlew CC, et al. Refining the operative
curriculum of the acute care surgery fellowship. J Trauma Acute
Care Surg 2015; 78(1):192-6.
4 Cubas RF, Gomez NR, Rodriguez S, et al. Outcomes in the
management of appendicitis and cholecystitis in the setting of a
new acute care surgery service model: impact on timing and cost. J
Am Coll Surg 2012; 215(5):715-21.
5 Earley AS, Pryor JP, Kim PK, et al. An acute care surgery
model improves outcomes in patients with appendicitis. Ann Surg
2006; 244(4):498-504.
6 Fu CY, Huang HC, Chen RJ, et al. Implementation of the acute
care surgery model provides benefits in the surgical treatment of
the acute appendicitis. Am J Surg 2014; 208(5):794-9.
7 Wright GP, Ecker AM, Hobbs DJ, et al. Old dogs and new tricks:
length of stay for appendicitis improves with an acute care surgery
program and transition from private surgical practice to
multispecialty group practice. Am Surg 2014; 80(12):1250-5.
8 Britt RC, Bouchard C, Weireter LJ, et al. Impact of acute care
surgery on biliary disease. J Am Coll Surg 2010; 210(5):595-9,
599-601.
9 Lau B, Difronzo LA. An acute care surgery model improves
timeliness of care and reduces hospital stay for patients with
acute cholecystitis. Am Surg 2011; 77(10):1318-21.
10 Lim DW, Ozegovic D, Khadaroo RG, et al. Impact of an acute
care surgery model with a dedicated daytime operating room on
outcomes and timeliness of care in patients with biliary tract
disease. World J Surg 2013; 37(10):2266-72.
11 Michailidou M, Kulvatunyou N, Friese RS, et al. Time and cost
analysis of gallbladder surgery under the acute care surgery model.
J Trauma Acute Care Surg 2014; 76(3):710-4.
12 Barnes SL, Cooper CJ, Coughenour JP, et al. Impact of acute
care surgery to departmental productivity. J Trauma 2011;
71(4):1027-32; discussion 1033-4.
13 Buie VC OM, DeFrances CJ, Golosinskiy A. National Hospital
Discharge Survey: 2006 Annual Summary. Vital Health Stat
2010(168).
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CONTINUING EDUCATIONInstructions:UPMC prints Trauma Rounds with
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